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Allergic and Non‐Allergic Sinusitis for the Primary Care Physician: Pathophysiology, Evaluation and Treatment Daniel G. Becker, MD Clinical Associate Professor Department of Otolaryngology‐Head and Neck Surgery University of Pennsylvania Philadelphia, Pennsylvania Samuel S. Becker, MD Clinical Instructor, Vanderbilt University Clinical Assistant Professor Department of Otolaryngology‐Head and Neck Surgery University of Pennsylvania Philadelphia, Pennsylvania Copyright© 2110, Daniel G. Becker, MD and Samuel S. Becker, M.D. All rights reserved Allergic and Non‐Allergic Sinusitis for the Primary Care Physician: Pathophysiology, Evaluation and Treatment TABLE OF CONTENTS INTRODUCTION Chapter 1: ANATOMY AND PHYSIOLOGY WITH SINUSITIS OVERVIEW Chapter 1: Questions Chapter 2: SINUS SIGNS AND SYMPTOMS Chapter 2: Questions Chapter 3: MAKING THE DIAGNOSIS Chapter 3: Questions Chapter 4: ALLERGIC RHINITIS Chapter 4: Questions Chapter 5: ASTHMA AND SINUSITIS Chapter 5: Questions Chapter 6: ACID REFLUX AND SINUSITIS Chapter 6: Questions Chapter 7: SNORING Chapter 7: Questions Chapter 8: UNUSUAL CAUSES OF SINUSITIS Chapter 8: Questions Chapter 9: SINUSITIS IN PATIENTS WHO HAVE HAD SURGERY Chapter 9: Questions Chapter 10: MEDICAL TREATMENT OF SINUSITIS Chapter 10: Questions Chapter 11: SURGICAL TREATMENT OF SINUSITIS Chapter 11: Questions Chapter 12: SURGERY OF THE SEPTUM, THE TURBINATES, AND OTHER "NON-SINUS" CAUSES OF NASAL BLOCKAGE Chapter 12: Questions Allergic and Non‐Allergic Sinusitis for the Primary Care Physician: Pathophysiology, Evaluation and Treatment INTRODUCTION Sinusitis is one of the most common health care complaints in the United States. (1‐9) Approximately 1 in 8 people in the United States will have sinusitis at one time in their lives. The National Center for Disease Statistics reports that sinusitis is now the number one chronic illness for all age groups in the United States. The 1993 National Health Interview Survey found that sinusitis was the most commonly reported chronic disease, affecting approximately 14% of the United States population.(2) Sinus disease affects roughly 31 million people annually. Between 1990 and 1992, reports indicated that sinusitis sufferers had approximately 73 million days of restricted activity—a 50% increase from 4 years earlier. (3) Sinusitis accounted for nearly 25 million physician office visits in the United States in 1993 and 1994. (3) (Of course, many more cases are unreported, and many patients suffer without seeing a physician, so the true incidence of sinusitis is unknown.) Although they are typically not serious and respond promptly to proper medical treatment, inflammatory diseases of the sinuses are a leading cause of loss of productivity both at work and at school. An estimated 32.3 million people in the United States have chronic sinusitis. (3) Furthermore, 10% of the population suffers from allergic sinus disease. (3) The cost of treating sinus disease runs into the billions of dollars, without taking into account loss of work. Given the trend toward rationedmedical care, physicians are increasingly working toward an effective means of both early diagnosis and followup in these patients. Until recently, sinusitis has been an undertreated disease. Its drastic negative effect on quality of life has been generally underappreciated and unrecognized. Recent studies show that patients score the effects of chronic sinus disease in areas such as bodily pain and social functioning as more debilitating than diseases such as angina, congestive heart failure, emphysema, chronic bronchitis, and lower back pain, to name just a few. (2‐3) It is estimated that 2.2 billion dollars is spent yearly on prescription and nonprescription medication.(4) Overall health expenditures for sinusitis in 1996 were estimated at approximately 5.8 billion dollars, with 1.8 billion of that being spent on children 12 years and younger. (5, 6, 7) In the past, many patients were told they would just have to “live with it.” Since the introduction of endoscopic techniques for diagnosis of sinus disease in the United States in 1985, increased attention has been directed to this problem. Medical therapy may be recommended in the face of nasal symptoms and mucosal disease. Typical medications used in the treatment of mucosal disease include oral antibiotics, steroids, mucolytics, nasal steroid spray, nasal saline spray, oral decongestants, and oral antihistamines. The selection of appropriate medications depends upon the determination of the diagnosis. For example, many times antibiotics are prescribed without first obtaining a sinus culture. Inadequate duration and breadth of treatment may result in persistent and recurrent symptoms, and also in the development of resistant bacteria. A number of factors are felt to be important in the increasing incidence of sinusitis. Inhaled allergens and irritating air pollutants are detrimental to the sinuses and are on the rise. Global warming and the related increases in air pollution also affect the sinuses. Cigarette smoke is also detrimental to the sinuses, not only for the smokers, but also those exposed to secondhand smoke. While the incidence of sinusitis is on the rise, there have also been enormous improvements in the past 15 years in the ability to diagnose and treat these problems. This is largely because of technological advances in nasal endoscopy and X‐ray imaging. Also, the development of newer, more powerful medications including new antibiotics, antihistamines, and others, and significant advances in surgical treatment have played a major role in improved patient care. Sinusitis is the most common chronic health care condition in the United States, and its incidence is increasing. Fortunately, there have been significant advances in the diagnosis and treatment of this problem. This CME activity responds to the continuing need of practicing physicians to update their knowledge. This CME activity is designed to provide primary care physicians with the most up‐to‐date information about allergic and non‐allergic sinusitis and its treatment. REFERENCES 1. Melen I. Chronic sinusitis: clinical and pathophysiological aspects. Acta Otolaryngol Suppl (Stockh) 1994; 515:45‐ 48. 2. Gliklich RE, Metson R. The health impact of chronic sinusitis in patients seeking otolaryngologic care. Otolaryngol Head Neck Surg 1995; 113:104–109. 3. Gliklich RE, Hilinski JM. Longitudinal sensitivity of generic and specific health measures in chronic sinusitis. Qual Life Res 1995: 4:27–32. 4. Gliklich, RE, Metson R. The health impact of chronic sinusitis in patients seeking otolaryngologic care. Otolaryngol Head Neck Surg 1995; 113:104–109. 5. Ray NF, Baraniuk JN, Thamer M. Direct expenditures for the treatment of allergic rhinoconjunctivitis in 1996, including the contributions of related airway illnesses. J Allergy Clin Immunol 1999; 103: 401–407. 6. Ray NF, Baraniuk JN, Thamer M. Healthcare expenditures for sinusitis in 1996; contributions of asthma, rhinitis, and other airway disorders. J Allergy Clin Immunol 1999; 103: 408–414. 7. Pankey GA, Gross CW, Mendelsohn MG. Contemporary Diagnosis and Management of Sinusitis.Newtown PA: Handbooks in Health Care, 2000. 8. Dereberry J, Meltzer E, Nathan RA, Stang PE, Campbell UB, Corrao M, Stanford R. Otolaryngol Head Neck Surg, 2008 Aug;139(2):198‐205. Rhinitis symptoms and comorbidities in the United States: burden of rhinitis in America survey 9. Kennedy DW, Bolger WE, Zinreich SJ. Diseases of the Sinuses: Diagnosis and Managemet,London:BC Decker, 2001 Allergic and Non‐Allergic Sinusitis for the Primary Care Physician: Pathophysiology, Evaluation and Treatment CHAPTER 1 SINUS ANATOMY AND PHYSIOLOGY WITH SINUSITIS OVERVIEW DEFINITIONS The sinuses are chambers in the bones of the face and skull that are normally lined with a thin mucus producing membrane (called mucosa). There are four paired paranasal sinuses—the maxillary, ethmoid, frontal, and sphenoid sinuses (Fıg. 1). They communicate with the nasal cavity via narrow openings. Air and mucus enter and exit the sinus through these openings. Blockage of the small openings from swelling (caused by infection, allergy, and other causes) can result in sinusitis. (1,2,3) SINUSITIS Sinusitis literally means “inflammation of the sinus cavities.” (4‐6) This inflammation is what happens occurs when a patient’s nose and sinuses are exposed to anything that might irritate the membranous linings. These irritants may include dust and pollution, cigarette smoke, and other irritants. Allergic reaction to mold, pollen, and so forth may also irritate the nasal linings. Furthermore, infection by a virus or bacteria may irritate the nasal linings. The swelling that occurs may cause the narrow openings in the nose and sinus cavities to narrow even further or even to shutclose entirely. Thick abnormal mucus secretions can also block the sinuses further. Rhinitis refers to inflammation of the nasal mucosal linings only. Sinusitis refers to inflammation of the mucosal linings of the sinuses and is usually associated with and often preceded by rhinitis. Because the two go together, ear, nose, and throat specialists today often use the term rhinosinusitis. However, the words rhinitis, sinusitis and rhinosinusitis are often used interchangeably. In this article, we will use the term sinusitis to mean inflammation of the sinus and nasal passageways. Experts on sinusitis have tried to precisely define sinusitis. The Rhinosinusitis Task Force of the American Rhinologic Society has defined rhinosinusitis as a condition manifested by an inflammatory response involving the mucous membranes of the nasal cavity and paranasal sinuses, fluids within the cavities, and/or underlying bone. (4‐6). Symptoms associated with rhinosinusitis include nasal obstruction, nasal congestion and discharge, post‐ nasal drip, facial pressure and pain, cough, and others. (Table 1). A strong history consistent with chronic sinusitis includes the presence of two or more major factors or one major and two minor factors for greater than 12 weeks. (4‐6). TABLE 1: Factors Associated with the Diagnosis of Chronic Rhinosinusitis Major factors Minor factors Facial pain/pressure* Headache Facial congestion/fullness Fever Nasal obstruction/blockage Halitosis Nasal discharge/purulence/discolored nasal drainage Fatigue Hyposmia/anosmia Dental pain Purulence in nasal cavity on examination Cough Ear pain/pressure/fullness *Facial pain/pressure alone does not constitute a suggestive history for chronic rhinosinusitis in the absence of another major nasal symptom or sign. ANATOMY Sinus development continues throughout childhood, and is usually complete by adolescence (Figure 1). (1,2) Most people have all eight sinuses present by this time, although in a minority of patients some of the sinuses do not fully form. These hypoplastic (incompletely formed) or aplastic sinuses (completely unformed) are often an incidental finding, usually not associated with any increased sinus problems, although in some instances they should be addressed. (7‐10) FIGURE 1 – Coronal (upper illustration) and sagittal (lower illustration) views into the paranasal sinuses. The sinuses communicate with the nasal cavity via narrow openings called ostia. (11) Ostia drain into spaces within the nose called meati which are bordered by vertically oriented bones known as turbinates. The tear duct (naso‐lacrimal duct) drains into the inferior meatus (which is bordered by the inferior turbinate bone). This is one reason why our nose drips when we cry. The maxillary, frontal, and ethmoid sinuses drain into the middle meatus, which is bordered by the middle turbinate bone (FIGURE 2). Some of the ethmoid sinuses also drain into the superior meatus, which is a space defined by superior turbinate bone. While the maxillary, frontal, and sphenoid sinuses are solitary, well‐defined compartments, the ethmoid sinus is – in actuality – a collection of several small sinuses, structured like a beehive. It is for this reason that the ethmoid sinuses have varied drainage patterns. The sphenoid sinus drains into the spheno‐ethmoidal recess, located between the superior turbinate bone and the nasal septum. (3, 11, 12) Air and mucus enter and exit the sinus through the sinus ostia. The functions of the nose and sinuses include olfaction (sense of smell), respiration, and defense. (3, 11, 12) The nose and sinuses produce mucus to keep the nasal and upper respiratory passageways moist, and have an effect on vocal resonance. Among the important physiological roles of the sinuses are the humidification and warming of inspired air, and the removal of particulate matter from this air. Humidification and warming of inspired air are accomplished by the watery secretions of the serous glands, which can produce up to 1–2 liters of secretions per day. FIGURE 2 – The maxillary, frontal, and ethmoid sinuses drain into the middle meatus, which is bordered by the middle turbinate bone. The osteomeatal complex (OMC) is the Grand Central Station of the sinuses. Any process that causes swelling and blockage of this critical area contributes to the symptoms of sinusitis. While the watery serous secretions play a role in humidification and warming, the secretions of the goblet cells and mucous glands facilitate the removal of particulate matter. This mucous is very effective, trapping up to 80% of particles larger than 3–5 microns. (3) This includes not only inorganic pathogens but also up to 75% of the bacteria entering the nose. (3) The mucous blanket of the nose is a very dynamic structure, continuously renewing itself every 10–20 minutes. (3) The mucous blanket also defends the body against infection. Besides trapping organic pathogens, the blanket constitutes a rich immunologic barrier within the mucosa. When exposed to the trapped antigens, it can further enhance the response by stimulating the immune system. The ciliated epithelium continually beats, propelling the mucus in a synchronized fashion toward the natural opening or ostium of each sinus. These ostia drain into the nasal cavity. The mucus is then propelled to the nasopharynx to be swallowed. At this point the acid secretions of the stomach can help destroy the inhaled pathogens. (3, 11‐13) 10 soft tissue and bone. Built‐in suction continuously removes blood, secretions, and debris and maintains a clear surgical field. Newer modifications of the shaving cannulas enable a combination of soft tissue and thin bone resection known as micro‐excision. Furthermore, the cannulas have become available in a variety of pre‐bent angles and bendable types for work in difficult areas such as the frontal recess or the maxillary sinus. The powered instruments offer the potential advantages of less trauma, decreased bleeding, shorter surgical time, greater comfort, improved recovery, and more rapid healing. FIGURE 3 – Powered instrumentation, also known as microdebriders or soft tissue shavers, represents one of the more recent advances in endoscopic sinus surgery. Powered instruments have been clearly established as a central tool for minimally invasive endoscopic sinus surgery. The use of powered instrumentation has become almost standard in sinus surgery because these instruments offer the endoscopic surgeon great technical precision. The most dramatic advantage of powered instrumentation has been seen in treatment for nasal polyps. Traditionally, nasal polyp surgery has been performed with manual instruments that work by avulsion of the polyps. This causes tearing of the tissues, which can include adjacent normal mucosa. As a result, the field is often obscured by blood, thereby increasing the potential to damage important structures. For these reasons, it was not uncommon for the surgeon to abort the procedure before all the polyps had been removed. These patients also almost invariably required nasal packing for at least 24 hours. The soft tissue shaver helps make this procedure routine. The shaver allows for excellent visualization of the anatomy while the polyps are precisely and quickly removed. Because the oscillating blade is guarded, important structures are less likely to be damaged. The continuous suction allows relatively uninterrupted dissection in a clear 142 field. Packing is usually not required. Overall, a more complete removal is possible with less bleeding and greater comfort. Guarded bone drilling burs are also available in various configurations for removal of larger quantities of more dense bone. For example, these burs are used in frontal sinus “drillout” procedures to reestablish proper frontal sinus drainage in some advanced cases of chronic frontal sinusitis (FIGURE 4). FIGURE 4 – Guarded bone drilling burs are also available in various configurations for removal of larger quantities of more dense bone. For example, burs are used in frontal sinus “drillout” procedures to reestablish proper frontal sinus drainage in some advanced cases of chronic frontal sinusitis. The removal of bone undertaken in this procedure, and the kind of improvement possible for the drainage pathway in these patients, is illustrated in this skull specimen before (a) and after (b) drilling away of the frontal sinus floor. B. Computer‐Assisted Surgery Computer‐assisted surgery, (1‐3,24,28‐30) also known as image guided surgery, was initially developed for accurate localization during neurosurgical procedures. The application of this technique in endoscopic sinus surgery is available in many major centers. This system allows the surgeon to localize the tip of the surgical instrument in the paranasal sinuses, generally within 1‐2 mm of accuracy on coronal, axial, and sagittal CT images (FIGURE 5). Computer‐assisted endoscopic sinus surgery can potentially aid the surgeon, especially when working in or near difficult areas such as the frontal sinuses, sphenoid sinus, skull base, and orbit. Computer‐assisted endoscopic sinus surgery is especially useful in cases with poor surgical landmarks caused by previous surgery, dense scarring, or 143 extensive disease. These systems are not universally available. While they are helpful in specific cases, they are not necessary for an experienced, skillful surgeon to perform difficult procedures. They are not, at this stage, associated with decreased surgical risk, although many surgeons feel they add an extra layer of security when operating along the anterior skull base (roof of the sinus cavities). FIGURE 5 – Computer‐assisted surgery was initially developed for accurate localization during neurosurgical procedures. The application of this technique in endoscopic sinus surgery is available in many major centers. This system allows the surgeon to localize the tip of the surgical instrument in the paranasal sinuses, generally within 2 mm of accuracy on coronal, axial, and sagittal CT images POSTOPERATIVE VISITS Postoperative visits are an indispensable part of the surgery and help promote healing and prevent persistent or recurrent disease. Follow‐up visits are usually arranged at approximately 1 day, 1 week, 2 weeks, and 4 weeks after surgery to clean crusts from the nose. A family member or friend should drive the patient to and from the first postoperative visits, and thereafter as instructed by the surgeon. The patient should anticipate periodic visits to the surgeon’s office until healing is nearly completed (usually 4–6 weeks). During follow up visits, any persistent inflammation or scar tissue will be removed under local anesthesia. Although the chances of complications from these manipulations are rare, the potential risks are the same as with the surgery itself. Consent to surgery also includes consent to postoperative care. Careful postoperative care is essential to the success of this surgery. The patient will typically be provided with written 144 postoperative care instructions. It is very important that the patient follow these instructions, as well as any other instructions given by the surgeon, to promote healing and decrease the chance of complications. The postoperative care is as important as the surgery itself. Patients are instructed to use both saline nasal spray and saline irrigations in the nose several times a day to cleanse the nose of crust and clots. This maintains a healthy, moist environment that will heal well. Frequent endoscopic cleanings are performed as necessary to prevent formation of granulation tissue, adhesions, and scars that can re‐obstruct drainage of the sinuses. Usually the nasal mucosa has healed and normal mucociliary flow is reestablished within 6‐8 weeks. The patient can expect to experience some bleeding from their nose for several days after the surgery and again after each office debridement. This is normal and slowly improves. If bleeding is severe or persists for an extended period of time, the patient should notify the surgeon’s office. As the sinuses begin to clear themselves after 2–3 weeks, the patient can expect to have some thick brown drainage from their nose. This is mucus and old blood. This is expected and does not indicate an infection. The patient may experience some discomfort postoperatively due to manipulation and inflammation. The patient should take pain medication as directed (often extra‐strength acetaminophen is sufficient). The surgeon may advise the patient to take medication for pain prior to the postoperative visits, when the nose is most sensitive. If the medication is sedating, the patient should be sure to have someone available to provide transportation to and from the visit. Patients who undergo FESS for extensive sinonasal polyps require continued surveillance for months to years. The sinuses of post‐FESS patients are typically easily accessible with office nasal endoscopy. Earlier regrowth of polyps can be identified and controlled by removing the polyps endoscopically in the office setting. Sinusitis is a chronic problem, and while symptoms may improve or even disappear after surgery, the patient’s nose and sinuses still have the potential to be irritated by pollen, dust, pollution, etc. The patient should realize that some medical therapy is usually continued after surgery, especially if allergy or polyps play a role in the sinus disease. This is necessary to control or prevent recurrence of disease. Overall, the majority of patients have had significant improvement with the combination of surgery and continued medical management. FESS, performed 145 as a result of medical therapy failures in acute and chronic sinusitis, is associated with a success rate of 75–95%, according to sources in the literature. (31‐33) RESULTS OF FESS Overall, the majority of patients have had significant improvement with the combination of surgery and continued medical management. FESS performed as a result of medical therapy failures in acute and chronic sinusitis is associated with a success rate of 75–95%, according to sources in the literature. (31‐35) Endoscopic sinus surgery is generally well tolerated with a brief recovery period (35) Chester and others report that fatigue and bodily pain is clinically and statistically improved by surgery. (36‐38) Patients with severe fatigue showed a more pronounced improvement than patients less severely fatigued. (37) Significantly greater improvement occurs in patients with fibromyalgia and in patients that are more severely fatigued at presentation, compared to patients with mild fatigue. (37) Soler et al (2008) report that nasal congestion, fatigue, decreased sense of smell , nasal drainage, and facial pain‐pressure showed significant and sustainable postoperative improvement at 3, 6, 12, and 18 months after surgery. (39) DISCUSSION AND CONCLUSIONS In the 21st Century, state‐of‐the‐art technology facilitates the sinus surgeon’s ability to open obstructed sinus passageways. The advent of endoscopic techniques and the introduction of powered instrumentation and image guidance allow a minimally invasive, endoscopic approach to sinus surgery. REFERENCES 1. Kennedy DW, Senior BA. Endoscopic sinus surgery. A review. Otolaryngol Clin North Am 1997; 30:313–330. 2. Kennedy DW, Bolger WE, Zinreich SJ. Diseases of the Sinuses: Diagnosis and Management. London:BC Decker, 2001. 3. Stamm A, Draf W. Micro‐endoscopic Surgery of the Paranasal Sinuses and the Skull Base. New York:Springer Verlag, 2000. 146 4. Stankiewicz JA. Complications of sinus surgery. In: Bailey BJ, editor. Head and Neck Surgery‐Otolaryngology. Philadelphia, PA: JB Lippincott 1993: 413–427. 5. Levine HL, May M. Complex anatomy of the lateral nasal wall: simplified for the endoscopic sinus surgeon. In: Levine HL, May M, editors. Endoscopic Sinus Surgery. New York: Thieme Medical Publishers,1993:1–28. 6. Gustafson RO, Bansberg SF. Sinus surgery. In: Bailey BJ, ed. Head and Neck Surgery‐Otolaryngology. Philadelphia, PA: JB Lippincott, 1993: 377–388. 7. Lanza CL, Kennedy DW. Endoscopic sinus surgery. In: Bailey BJ, ed. Head and Neck Surgery‐Otolaryngology. Philadelphia, PA: JB Lippincott 1993, pp 389–401. 8. Rice DH. Endoscopic sinus surgery. Otolaryngol Clin North Am 1993; 26:613–618. 9. Becker DG, Becker SS. www.SinusTreatmentCenter.com , Verio Publishing, 2002. 10. Siow JK, Al Kadah B, Werner JA. Balloon sinuplasty: a current hot topic in rhinology. Eur Arch Otorhinolaryngol. 2008 May;265(5):509‐11. Epub 2008 Feb 26. Review. 11. Vaughan WC. Review of balloon sinuplasty. Curr Opin Otolaryngol Head Neck Surg. 2008 Feb;16(1):2‐9. 12. Brehmer D.[Catheter‐based balloon dilatation of the frontal, maxillary and sphenoid ostia: a new procedure in sinus surgery] HNO. 2008 Jan;56(1):65‐70. German. 13. Chandra RK. Estimate of radiation dose to the lens in balloon sinuplasty. Otolaryngol Head Neck Surg. 2007 Dec;137(6):953‐5. 14. Christmas DA, Mirante JP, Yanagisawa E. Endoscopic view of balloon cather dilation of sinus ostia (balloon sinuplasty) Ear Nose Throat J. 2006 Nov;85(11):698, 700. 15. Lanza DC, Kennedy DW. Balloon sinuplasty: not ready for prime time. Ann Otol Rhinol Laryngol. 2006 Oct;115(10):789‐90; discussion 791‐2. 16 Bolger WE, Brown CL, Church CA, Goldberg AN, Karanfilov B, Kuhn FA, Levine HL, Sillers MJ, Vaughan WC, Weiss RL.Safety and outcomes of balloon catheter sinuplasty: a multicenter 24‐week analysis in 115 patients. Otolaryngol Head Neck Surg. 2007 Jul;137(1):10‐20. 17. Gross CW, Avner TG, Becker DG. Sinusitis in children. In: Gates GA, ed. Current Therapy in Otolaryngology‐Head Neck Surgery. 5 ed. St. Louis, MO:Mosby Year Book 1994: 373–377. 18. Gross CW, Lazar RH, Gurucharri MJ. Pediatric functional endonasal sinus surgery. Otolaryngology Clin North Am 1989; 22:733–738. 19. Gross CW, Gurucharri MJ, Lazar RH. Functional endonasal sinus surgery (FESS) in the pediatric age group. Laryngoscope 1989; 99:272–275. 20. Lazar, RH, Younis RT, Long TE. Functional endonasal sinus surgery in adults and children. Laryngoscope 1993;103:1–5. 21. Lusk RP. Pediatric Sinusitis. New York: Raven, 1992. 147 22. Manning SC. Pediatric sinusitis. Otolaryngol Clin North Am 1993; 26:623–638. 23. Setliff RC. Parsons DS. The “hummer”: new instrumentation for functional endoscopic sinus surgery. Am J Rhinol 1994; 8:275–278. 24. Gross CW, Becker DG. Advances in sinus and nasal surgery. Otolaryngol Clin North Am. 1997; 30: xiii–xiv. 25. Gross WE. Soft‐tissue shavers in functional endoscopic sinus surgery (standard technique). Otolaryngol Clin North Am 1997; 30:435–441. 26. Setliff RC. Th e small‐hole technique in endoscopic sinus surgery. Otolaryngol Clin N Am 1997; 30:341–354. 27. Becker DG. Technical considerations in powered instrumentation. Otolaryngol Clin North Am 1997; 30:421–434. 28. Becker DG. Powered instrumentation and image guidance in endoscopic sinus surgery. Jpn J Rhinol 2000; 4(1):79–83. 29. Anon JB, Klimek L, Mosges R. Computer assisted endoscopic sinus surgery. An international review. Otolaryngol Clin North Am 1997; 30:389–401. 30. Fried MP. Intraoperative computerized imaging for endoscopic sinus surgery. Vanderbilt University Sinus Newsletter, Spring 1197. 31. Gliklich RE, Metson R. Effect of sinus surgery on quality of life. Otolaryngol Head Neck Surg 1997;117:12–17. 32. Hoffman SR, Mahoney MC, Chmiel JP. Symptom relief after endoscopic sinus surgery: an outcomesbased study. Ear Nose Th roat J 1993;72:413–414, 419–420. 33. Winstead W, Barnett SN. Impact of endoscopic sinus surgery on global health perception; an outcomes study. Otolaryngol Head Neck Surg 1998; 119:486–491. 34. Poetker DM, Litvack JR, Mace JC, Smith TL. Am J Rhinol. 2008 May‐Jun;22(3):329‐33. Recurrent acute rhinosinusitis: presentation and outcomes of sinus surgery. 35. Mehta U, Huber TC, Sindwani R. Otolaryngol Head Neck Surg. 2006 Mar;134(3):483‐7. Patient expectations and recovery following endoscopic sinus surgery. 36. Chester AC, Sindwani R, Smith TL, Bhattacharyya N. Systematic review of change in bodily pain after sinus surgery.Otolaryngol Head Neck Surg. 2008 Dec;139(6):759‐65. 37. Sautter NB, Mace J, Chester AC, Smith TL. The effects of endoscopic sinus surgery on level of fatigue in patients with chronic rhinosinusitis. Am J Rhinol. 2008 Jul‐Aug;22(4):420‐6. 38. Chester AC, Sindwani R, Smith TL, Bhattacharyya N. Fatigue improvement following endoscopic sinus surgery: a systematic review and meta‐analysis. Laryngoscope. 2008 Apr;118(4):730‐9. 39. Soler ZM, Mace J, Smith TL. Symptom‐based presentation of chronic rhinosinusitis and symptom‐specific outcomes after endoscopic sinus surgery. Am J Rhinol. 2008 May‐Jun;22(3):297‐301. 148 Allergic and Non‐Allergic Sinusitis for the Primary Care Physician: Pathophysiology, Evaluation and Treatment CHAPTER 11 QUESTIONS 1. Absolute indications for sinus surgery include all of the following except for: A B C D Orbital abscess arising from a sinus infection Chronic rhinosinusitis Invasive fungal sinusitis Cerebrospinal fluid rhinorrhea 2. Known risks of sinus surgery include all of the following except A. B. C. D. Decrease of sense of smell Cerebrospinal fluid leaks Decrease of hearing acuity Damage or the eye and vision 3. Success rates of sinus surgery are thought to be: A B C D 0‐25% 25‐50% 50‐75% Greater than 75% 4. Several studies have shown that sinus surgery performed with image‐guidance stereotactic navigational systems is associated with improved outcomes and decreased surgical risk. A True B False 5. Which of the following is a small compartment located in the region between the middle turbinate and the lateral nasal wall in the middle meatus, and represents the key region for drainage of the anterior ethmoid, maxillary, and frontal sinuses. Obstruction of this compartment causes a vicious cycle of events that may lead to sinusitis. A B C D Frontal sinus drainage pathway Osteomeatal complex Sphenoethmoidal recess Ethmoturbinal ridge 149 Allergic and Non‐Allergic Sinusitis for the Primary Care Physician: Pathophysiology, Evaluation and Treatment CHAPTER 12 SURGICAL MANAGEMENT OF THE SEPTUM, TURBINATES, AND OTHER “NON‐SINUS” CAUSES OF NASAL OBSTRUCTION INTRODUCTION A detailed history and physical examination are critical first steps in the evaluation and treatment of every patient presenting with nasal obstruction. This review has focused on the sinuses, and it is true that chronic nasal obstruction is the most common presenting symptom of anterior ethmoid sinus disease. Still, there are other causes of nasal obstruction, these include septal deviation, inferior turbinate hypertrophy, nasal valve collapse, air filled middle turbinates (concha bullosa), polyps (FIGURE 1A), tumors, and others (TABLE 1). In this chapter, we will briefly discuss the surgical management of the deviated septum, and the inferior turbinates. FIGURE 1A – Nasal polyps may cause nasal obstruction. This endoscopic photograph demonstrates nasal polyps emanating from the middle meatus into the nasal cavity. 150 Table 1. Differential diagnosis of nasal obstruction Cause Allergic Congenital Chronic rhinosinusitis Endocrine Iatrogenic Infection Inflammatory polyposis Mechanical Medicinal Neoplastic Foreign body Nasal cycle Other SEPTUM Example Allergic rhinitis Encephalocele (iatrogenic or posttraumatic), glioma, teratoma Pregnancy, hypothyroidism, adrenal insufficiency, menstruation Atrophic rhinitis, overresection, overnarrowing after osteotomies Acute and chronic rhinosinusitis, septal abscess Deviated septum, nasal valve collapse, synechiae, nasal polyps, inferior turbinate hypertrophy, middle turbinate hypertrophy (including concha bullosa), adenoid hypertrophy, choanal atresia, septal hematoma Rhinitis medicamentosa Benign and malignant nasal tumors The septum is the wall that divides the nose down the middle, into a right and left side. It is made of cartilage and bone and has a mucous membrane lining on both sides. When the septum is straight, it simply acts as the divider of the nose and allows for streamlined, aerodynamic airflow and easy nasal breathing. While the septum may be slightly deviated to one side or the other in many patients, in some patients this deviation will cause a functional obstruction. If it is substantially deviated or twisted, the septum can cause nasal obstruction. The septum can twist to the right and block the right side, and then come around further back in the nose and twist to the left to block the left side as well. Some areas in particular are more likely to cause functional obstruction. The front of the nares – the “nasal vestibule” – is the most narrow portion of the nasal airway. Deviation in this already narrow area (Caudal Septum) will also often lead to functional obstruction. (Figure) (1‐5) 151 METHODS – SEPTOPLASTY There is no medicine that can straighten a deviated septum. If the septum is causing nasal obstruction, only surgery can correct it. This surgery is called a septoplasty. A septoplasty is performed through a small incision made on the inside of the nose (no external incision is typically necessary). The lining of the septum—the mucous membranes—are lifted off of the cartilage and bone. The cartilage and bone are sculpted and repositioned, and a portion may be removed to achieve the desired straightening of the septum. The mucous membrane lining is then sewn back together with absorbable sutures (no stitch removal is necessary). In the authors’ practice, no nasal packing is placed. Packing was used traditionally and is still used by many surgeons today. However, experienced surgeons have found that packing is not necessary in their hands. This is helpful because packing can be extremely painful, and it can be associated with the risk of Toxic Shock Syndrome. (1‐ 6) ENDOSCOPIC SEPTOPLASTY Surgeons who are trained in endoscopic techniques may use the endoscopic approach in certain situations. Endoscopically guided septoplasty is useful in difficult revision nasal surgeries in which obstructing septal deviation persists. For example, if septal deviation persists posteriorly after a septoplasty, persisting nasal obstruction may require revision septoplasty. Because the mucosal flaps are often densely adherent after a septoplasty, revision septoplasty involving a traditional approach may present technical difficulty, including significant risk of septal perforation. Endoscopic septoplasty is a relatively recent and important technique and makes this repair significantly less difficult. The endoscopic approach may be a useful adjunct in difficult revision cases in which complete elevation of a mucoperichondrial flap presents difficulties, such as a persistent posterior septal obstruction after prior septoplasty or after septal injury (such as hematoma or abscess) with loss of cartilaginous septum. In these cases, typical surgical dissection planes are obliterated and complete elevation of a mucoperichondrial or mucoperiosteal flap 152 may be difficult. The ability to address a persisting deviation, elevating the mucosal flap directly over the offending deviation using endoscopic techniques greatly facilitates treatment. (7‐12) TURBINATES The inferior turbinates are highly vascular structures that extend from the front of the nose along the side of the nasal floor all the way back towards the opening into the throat (nasopharynx). These are the only structures within the nasal cavity that freely swell and shrink on a routine basis (the nasal cycle). When these structures are enlarged (hypertrophied), especially at the front of the nose, they can cause significant functional obstruction. In many instances patients with inferior turbinate hypertrophy can be managed with medical and allergy treatments. In other cases surgical reduction of the inferior turbinates may be indicated. (1, 13‐17) METHODS – INFERIOR TURBINATE REDUCTION Treatment of the inferior turbinates is a matter of some controversy. Some authors advocate inferior turbinate sacrifice as an almost routine treatment of nasal obstruction; others categorically advise against surgical reduction because of the risk of atrophic rhinitis. In our view, there should be a cautious, balanced approach. A thorough search to determine the cause of nasal obstruction is essential, and that cause should be addressed. The proper treatment of nasal obstruction is not simply turbinectomy. By the same token, it is unlikely that the inferior turbinates are immune from pathologic conditions; turbinate hypertrophy must be recognized. A graduated stepwise approach to the inferior turbinates is prudent. It is possible that atrophic rhinitis does develop in some patients after inferior turbinectomy, so we undertake this procedure with great caution. Also, newer techniques have been designed specifically to limit the incidence of atrophic rhinitis Radiofrequency (RF) volumetric tissue reduction uses radiofrequency heating to induce submucosal tissue destruction, leading to reduction of tissue volumes, represents a potentially conservative procedure that may be considered as an alternative to more aggressive approaches. When more aggressive treatment of the inferior turbinates is warranted, a submucosal elevation of the turbinate with or without resection of the bulky bone of the inferior concha is preferred. With newer techniques 153 using powered instrumention, the submucosal tissues of the inferior turbinate, which provide the bulk of the turbinate, can be removed in a fairly atraumatic fashion with a resultant decrease in the overall size of the turbinate. (1, 13‐17) FIGURE 2 – This patient had a caudal septal deviation and also had an excessively concave lateral crura contributing to nasal obstruction. In this case the caudal septum was straightened and the right lateral crus was excised and “flipped” to achieve both aesthetic improvement and improvement in the nasal valve area. (a,b) preoperative; (c,d) postoperative. (Reprinted with permission from www.therhinoplastycenter.com.) 154 CONCLUSION Careful evaluation of patients presenting with nasal obstruction should include a thorough history and physical examination, usually with nasal endoscopy. Identification of the correct source(s) of obstruction allows for an appropriate, targeted surgical intervention. REFERENCES 1. Becker DG. Septoplasty and Turbinate Surgery Aesthetic Surg J 2003;23:393‐403. 2. Tardy ME. Rhinoplasty: the art and the science. Philadelphia, PA: Saunders; 1997. 3. Becker DG, Kennedy DW. Functional endoscopic sinus surgery: a review. Russian J Rhinol 1998;1:4‐14. 4. Toriumi DM, Becker DG. Rhinoplasty dissection manual. Philadelphia, PA: Lippincott Williams & Wilkins; 1999. 5. Beeson WH. The nasal septum. Otol Clin North Am 1987;20:743‐767. 6. Pastorek NJ, Becker DG. Treating the caudal septal deflection. Arch Facial Plast Surg 2000;2:217‐220. 7. Lanza DC, Kennedy DW, Zinreich SJ. Nasal endoscopy and its surgical applications. In: Lee KJ, ed. Essential otolaryngology: head and neck surgery. 5th ed. New York, NY: Medical Examination Publishing; 1991:373‐387. 8. Lanza DC, Rosin DF, Kennedy DW. Endoscopic septal spur resection. Am J Rhinol 1993;7:213‐216. 9. Cantrell H. Limited septoplasty for endoscopic sinus surgery. Otolaryngol Head Neck Surg 1997;116:274‐277. 10. Giles WC, Gross CW, Abram AC, Green WM. Endoscopic septoplasty. Laryngoscope 1994;104:1507‐1509. 11. Hwang PH, McLaughlin RB, Lanza DC, Kennedy DW. Endoscopic septoplasty: indications, technique, and results. Otolaryngol Head Neck Surg 1999;120;678‐682. 12. Becker DG. Endoscopic septoplasty in functional septorhinoplasty. Operative Techniques in Otolaryngology‐Head & Neck Surgery. October 2000;10:25‐30. 13. Utley DS, Good RL, Hakim I. Radiofrequency energy tissue ablation for the treatment of nasal obstruction secondary to turbinate hypertrophy. Laryngoscope 1999;109:683‐686. 14. Smith TL, Correa AJ, Kuo T, Reinisch L. Radiofrequency tissue ablation of the inferior turbinates using a thermocouple feedback electrode. Laryngoscope 1999;109:1760‐1765. 15. Jafek BW, Dodson BT. Nasal obstruction. In: Bailey B, ed. Head & neck surgery: otolaryngology. 2nd ed. Philadelphia, PA: Lippincott‐Raven;2000;371‐397. 16. Lee K, Hwang P, Kingdom. Inferior Turbinate Reduction. Operative techniques. Otolaryngol Head Neck Surg 2001;12:107‐111. 17. Jackson LE, Koch RJ. Controversy in the management of inferior turbinate hypertrophy: a comprehensive review. Plast Reconstr Surg 1999;103:300‐312. 155 Allergic and Non‐Allergic Sinusitis for the Primary Care Physician: Pathophysiology, Evaluation and Treatment CHAPTER 12 QUESTIONS 1. Mechanical causes of nasal obstruction include all of following except for: A B C D Nasal polyps Adenoid hypertrophy Rhinitis medicamentosa Deviated nasal septum 2. What is the name of the most narrow portion of the nasal airway? A B C D Nasal vestibule Nasal angle Nasal corridor Nasal runway 3. Which of the following are the only structures within the nasal cavity that freely swell and shrink on a routine basis, and may lead to nasal obstruction? A. Inferior turbinate B. Middle turbinate C. Superior turbinate D. Supreme turbinate 4. Which approach may be most useful in resolving a persistent posterior septal deviation in a patient who has had a prior septoplasty? A Open septoplasty B Standard septoplasty C Endoscopic septoplasty D Rhinoplasty 5. Endocrine causes of nasal obstruction include all of the following except: A. Pregnancy B. Encephalocele C. Hypothyroidism D. Adrenal insufficiency 156 ... numbers, it is clear that the choice of plain films is fraught with error . FIGURE 5B – Maxillary and ethmoid sinuses? ? Figure 5C – Sphenoid sinuses 38 ? ? ? ? FIGURE 6 ? ?? A case of severe sinusitis with pansinus opacifi cation. The combination of nasal endoscopy and CT ... performing sinus surgery to improve efficacy and safety . FIGURE 5A – Anatomy of the frontal sinuses. The imaging procedure of? ? ? ?choice is the computerized tomography (CT) scan, which is recommended primarily in evaluating the extent and severity of disease in chronic sinusitis and ... food is bland or tasteless. Although annoying, this can actually be a more serious problem because the patient cannot tell if food is spoiled or if there is a household emergency such as fire, which they would not be able to detect. The nerves for smell are located in a very small area high in the nasal cavity. Even a small amount of blockage
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